Staff Article Posted October 25, 2014 Last updated August 11, 2017
Back pain relief is often the only thing on the mind of an individual who is suffering with low or mid back pain. The good news is that most back pain will usually resolve itself without medical intervention. The current research supports mobility. In other words, it is important to keep moving as much as possible.
A staggering 50 billion dollars are spent every year on Physical Therapy and Medical Doctor Office visits in the hope of reducing or eliminating low to mid back pain. The human body was designed to function more efficiently with regular daily movements. Blood and Lymphatic flow are improved with locomotion as well as joint lubrication and digestion.
The number one neurological complaint is headache, following up very closely in second place is low back pain. The greatest number of Americans to experience any health related condition will experience low back pain, it is no wonder that many are seeking back pain relief techniques.
When it comes to the primary hip flexor, this muscle named psoas is often overlooked or over worked by many manual therapists. This is a large muscle that works with the iliacus to produce hip flexion, and is often referred to as the iliopsoas (psoas is pronounced "so ass").
Here is the thing about the psoas, many massage schools spend a great deal of time teaching students how to "work the psoas". Then, there are many more massage training academies that barely even discuss the muscle. The muscle is a core mobility structure, so you can be sure that it is almost always sensitive. When a manual therapist who actually knows how to properly find the muscle, also finds that the client has sensitivity, does this mean the muscle actually needed to be "worked"?
In many cases, no it really did not need to be addressed. But, in some cases it can be involved in low back pain. We have two psoas, one on each side of the spine, which cross the pubic bones and attache to the lessor trochanter of the femurs. This orientation allows the muscle to pull the trunk toward the thigh and the thigh toward the trunk (hip flexion).
The psoas is a part of a pulley system that allows us to stand erect on two legs as opposed to all fours. When a psoas is in a constant contracted stated it is shortened. It does not need to be stretched because the position and function of the muscle make this concept practically impossible. Releasing the psoas into a relaxed state is a more manageable goal.
Here is the other thing about psoas, when it engages it pulls downward and forward on the lumbar vertebra, as mentioned above allowing us to stand erect. If a psoas remains contracted or shortened for too long it will compress the vertebra of the lower spine bringing them closer to the pelvis. As a result, of this compression another muscle is also forced to shorten. This other muscle is almost always named as a culprit of low back pain.
Quadratus Lumborum is responsible for hiking the hip and stabilizing the low back, while walking. It is often cited as having multiple trigger points that will refer pain across the low back, to the outside of the hip and into the top of the hamstrings. This muscle is discussed in detail below, as a part of our DIY trigger point therapy section.
In addition to the QL the spinal erectors are also placed into a chronically shortened position. Make sure you read the DIY trigger point therapy section, as it will discuss how to find and release TrgPts within the Erector Spinae as well as the QL. The erector muscles are another key to relieving low back pain.
One last thing about the psoas, we have two of them and although they may both become short at the same time, this is usually not the case. One side may become shortened bringing the hip bones closer to the lower spinal bones. When this happens the foot on that side will turn out and the shoulder on that side will appear to be lower than the other shoulder, as it is pulled forward and down to compensate.
This compensation results in rotation of the thoracic and lumbar spine. Which is required in order to keep our head facing forward so we can see where we are going. Now the question is how to release the psoas effectively?
and gently and it is best to do this yourself. By following one of the
simple mobilization techniques presented in the videos below. If the
psoas has become chronically shortened, repeat one or both of the
mobilizations on a regular basis. (p.s. If your psoas on one side is shortened your piriformis on the same side is also, which is why your foot turns out. see simple mobilization techniques for a piriformis release video) If low back pain persists or neither of your primary hip flexors are in a shortened or contracted state, then utilize the
DIY TrgPt therapy for low back pain presented below.
Next we will look at some trigger point therapy techniques that can help relieve low to mid back pain. To understand trigger point therapy it is important to take a look at the work of Dr. Janet Travell. Trigger points are thought to be caused by muscular overload. An overload does not necessarily mean that the individual has been performing heavy mechanical tasks. In this case muscular overload is a result of stimulatory overload of the neuromuscular junction within the muscle itself. Or more simply put an over stimulation of the nervous system which may be the result of intense physical activity, prolonged sleep posture or biochemical factors including the foods we eat and medications we are prescribed. The following list gives examples of possible causes of muscular overload:
Dr. Janet Travell found that providing stimulation to these developed muscularly overloaded points she named trigger points could reset the activity at the neuromuscular junction. Dr. Travell mapped out common trigger point referral zones. The self-treatment of these common trigger points and referral pain zones can lead to back pain relief.
What we have found working with trigger point therapy over the years and teaching clients how to treat these points themselves, is that pressure and pain thresholds are very individual. Each client had to try several types of treatment tools to fine the right size and firmness for them. The first go to tool is a tennis ball next lacrosse balls are very popular with athletes and then there is a wide range of specially designed trigger point massage balls, blocks and hand held tools.
A trigger point found in Gluteus Maximus and Gluteus Medius is step one in treating low back pain that radiates across the back just above the hip bones and just below the hip into the hamstrings. Some people may find this location in their butt to be the one that relieves most if not all their pain. It is also the spot where some may actually have superficial dimpling, although not everyone will see dimpling it can be useful in finding this important trigger point. In the image gluteus maximus is highlighted in light green and the gluteus medius is highlighted in a deeper green.
As can be seen from the image plate from Gray's Anatomy the gluteus maximus lies over the medial portion of the gluteus medius. The point we are interested in is the part where both muscles overlap and is indicated by the red star. Below is another image of this trigger point that highlights the gluteus medius. The orange area indicates the referral pain area experienced by most individuals tested. It is important to note that each person is unique and referral pain patterns can and will vary from person to person.
To Treat this Trigger Point Yourself Use One of the Following Methods:
The erector spinae muscles are a group of muscles that run along the spine, providing for trunk stability and extension. Treating trigger points in the erector spinea is step two. These trigger points tend to be localized and have a limited pain referral zone. They tend to be found at the cervical-thoracic junction at the edge of the shoulder blade, the mid back at the level of the floating ribs and at the level of the lower lumbar sacroiliac joint.
These are often the most compelling points for low back pain sufferers as they are located in the general region where they are feeling their pain. They have become known as the bridge between the cervical spine and the lumbopelvic hip complex. Any forward posturing will result in a significant increase in muscle loading resulting in low back pain. Therefore, strengthening core musculature with the help of a personal trainer or exercise physiologist can provide back pain relief.
It is reported over and over that releasing these muscles with enough force to penetrate to the multifidi muscles found beneath them as seen in the image on the lower left side, produces back pain relief. As a result, treatment of the erector spinae and the multifidus musculature with trigger point therapy is an ideal self-care technique for back pain relief.
Consequently, urgent chronic and acute pain can be reduced by applying pressure and circular friction to these points along the spinal column. The hidden code to unlock your future for living pain free is to understand how you, yourself can treat these easily located trigger points. Dr. Janet Travel mapped out what many believe are the most common trigger point fascial pull zones found within human musculature and structural fascia. Although not shown in the image below the erector spinae bundle at its attachment to the sacrum can refer pain into the top of the posterior thigh known as the hamstrings, therefore applying pressure and circular friction to this point can provide back pain relief.
To Treat These Trigger Points Yourself Use One Of The Following Methods:
Highlighted in light green, the multifidus muscles are seen in the image below. The multifidus muscles are found attached between the transverse processes of all vertebrae and all spinous processes of the vertebrae 2 to 4 vertebrae above the originating transverse process. The space found between the spinous process, the points that can be seen down the middle of the back, and the transverse process is called the lamina.
The space known as the lamina, is described as the lamina groove, as it runs up and down the spinal column on either side. As mentioned above, using enough pressure to penetrate deeply enough to effect the multifidi musculature can be life changing for certain individuals. To accomplish this you can use a pair of tennis balls or smaller racket balls if you are a smaller individual and tape them together or place them in a sock and tie them down.
Lie on the floor on your back with the balls between you and the floor. Roll the balls from the top of your shoulders to your hips by using your feet and legs, stopping and holding were ever you find pain. A large individual may be able to perform this technique with a small one to three pound dumbbell, the width of the spinal column can vary with the overall size of the individual.
Several trigger points found in the low back within the Qaudratus Lumborum muscle is step three in providing back pain relief. This muscle is often referred to as the hip hiker because we must hike our hip up each time we go to take a step. The QL muscle has several sets of trigger points. The 1st set is at its' attachment to the 12th rib. Both the most lateral portion of the muscle and the most medial portion of the muscle as it attaches to the transverse process of the spinal column or vertebrae. The second set is in the middle of the belly of this thick muscle, both along the lateral edge and at its attachment to the spinal column. The third set of trigger points can be found along its attachment to the top of the hip bone called the ilium, both at the lateral edge and as the muscle attaches to the spinal column.
The image below will help give you an idea of where this muscle will refer pain. Treating this muscle can provide for back pain relief. As can be seen in the image this muscle refers pain to the outside of the hip and into the top of the hamstring muscles.
To Treat These Trigger Points Yourself Use One of the Following Methods:
The use of of self-care trigger point work can be effective for many individuals, but for those hard to reach areas a professional trigger point massage may be called for. Although much has been written about trigger points, the good news is that any level of physical manual intervention can produce a positive change.
Dr. Janet Travell identified multiple treatment techniques including the use of cryotherapy to deactivate trigger points. For our purposes here constant pressure is a viable option that should not be overlooked. Constant pressure reduces blood flow depriving the area of oxygen, which in many cases has lead to a release of trigger points.
The intensity of the pressure should be strong, but your own comfort is the first priority. Your level of pain should remain within your own tolerance levels. Pain that forces other muscles to contract involuntarily is not as effective at restoring overall balance.
There is no specific response that will signify the release of a trigger point. The point may slowly cease to refer pain with repeated treatments over several days to weeks. Persistent trigger points may include scar tissue and regular treatment may help to manage chronic pain patterns.
Get Massage Smart always recommends that any individual experiencing low back pain, consult with their primary physician. To facilitate a full recovery and increase the odds of achieving back pain relief, strengthening and lengthening mobilizations can be utilized along with trigger point work. The low back is not fragile but day to day activities can result in muscular imbalances that need to be addressed.
When experiencing acute or severe low back to mid back pain that is preventing rest, the image to the left demonstrates two positions that may take the pressure off and reduce pain. Both of these are lying on the floor or a flat, firm surface with the knees bent and the neck supported, yet not hyper-flexed (chin close to or on the chest). The use of warm, moist heat is recommended over ice or cold. A cold pack on the lower back may increase sustained muscular contraction in effect increasing rather than decreasing pain.
A firm surface is necessary, so those of you who have a sleep number bed may be able to increase the firmness enough to support the first position in the above image. Another care, consideration may be the purchase of a massage table. This may sound a bit unusual, but if you do suffer frequently from back pain, you will be amazed at how useful it can be to take the pressure off the back by spending as little as 10 minutes in one of the above postures.
A massage table can be useful for individuals that can no longer comfortably lay on the floor or get up from the floor. A student model can cost as little as $99. One to two inches of padding is enough for this purpose. It is important to have a firm surface for this technique to help provide back pain relief. The table can be folded in half and placed under a bed or in a closet for storage.
To increase the flexion at the hip to 90 degrees is most beneficial. If a chair is not available a stack of books with a thick pillow may also work. A sturdy coffee or cocktail table may also serve for this purpose. The key component is a 90 degree flexion of the hip. It is also possible to provide mechanical traction if the chair or table allows one to hang their hips or pelvis from the seat or table surface. This should only be done for 8 to 10 minutes and if painful place your hips back on the solid surface. Mechanical traction can relieve pressure on the discs at the lumbar vertebra 4 and Lumbar vertebra 5 joints.
If you have purchased a massage table then using books is recommended to increase the bend of the legs and take pressure off the lower back. If your mattress has some sway to it and you are not ready to invest in a replacement, consider placing a sheet of plywood between the mattress and the box spring. Sleeping on a surface that is too soft or has deep depressions due to long term use may be a factor in back pain.
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